Provider Demographics
NPI:1942762711
Name:LINDBERG, BREANNA GRACE
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:GRACE
Last Name:LINDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228235 PINENUT RD
Mailing Address - Street 2:
Mailing Address - City:EDGAR
Mailing Address - State:WI
Mailing Address - Zip Code:54426-4485
Mailing Address - Country:US
Mailing Address - Phone:715-613-1314
Mailing Address - Fax:
Practice Address - Street 1:228235 PINENUT RD
Practice Address - Street 2:
Practice Address - City:EDGAR
Practice Address - State:WI
Practice Address - Zip Code:54426-4485
Practice Address - Country:US
Practice Address - Phone:715-613-1314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI223222163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse